Christian Health Care Center Ramapo Ridge Psychiatric Hospital Community Health Needs Assessment Implementation Strategy Year 1 Evaluation

Transcription

1 Christian Health Care Center Ramapo Ridge Psychiatric Hospital Community Health Needs Assessment Implementation Strategy Year 1 Evaluation Page 1

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3 Executive Summary On February 15, 2018, Christian Health Care Center s Ramapo Ridge Psychiatric Hospital (RRPH) held a Community Health Needs Assessment (CHNA) evaluation meeting. This meeting was facilitated by Kathy Roach, Community Health Improvement Project Manager of Strategy Solutions, Inc. A total of two hospital representatives attended this meeting to review RRPH s implementation strategies that have been underway over the last year. The evaluation meeting included a review of each of RRPH s goals, objectives, implementation strategies and accomplishments, along with objective discussion on what worked well, areas for improvement, continuing the objective for 2018, and updating the implementation action plan for the upcoming fiscal year. A detailed look at the implementation strategies for RRPH was conducted, determining what action items were started, completed or tabled during the first year of evaluation. RRPH retained the services of Strategy Solutions, Inc. in an advisory role to assist the hospital with the implementation of its action plan. Through this partnership, RRPH held three meetings during 2017 and 2018 to collect outcomes and impact measurements on the specific goals, objectives and action steps of the hospital s implementation strategy action plan. Significant accomplishments over the last year have been reported by RRPH and community partners. The Infographic and discussion below captures the 2016 Community Health Improvement Goals, as well as the 2017 significant accomplishments that occurred under those goals. A more detailed account of what was achieved during 2017 for each of the hospital s three goals can be found on pages 6-10 Progress Reports and Evaluation Discussion Goals Goal 1 In Collaboration with Stigma Free Wycoff, increase awareness of Mental Health and Substance Abuse through Educational Outreach Offerings Goal 2 Increase Access to Geriatric Specialized Care Page 3

4 RRPH made increasing awareness of mental health and substance abuse through educational outreach offerings a top priority when creating their implementation strategies to supplement their 2016 CHNA. Major accomplishments that the hospital made during 2017 to increase awareness of mental health and substance abuse through educational outreach offerings included: collaborated with Valley Hospital, Bergan Regional Medical Center, faith based organizations, YMCA, city of Wyckoff and Bergen County to offer various outreach educational activities throughout the year. Topics of the educational outreach included: anxiety, child/adolescent mental health, mental health stigma, mental health for veterans and domestic violence. RRPH also offered Stigma-Free Mental Health First Aid training for non-mental health professionals that had 25 attendees complete the program. The hospital created a mental health blog that was updated each month. RRPH also committed to increasing access to Geriatric specialized care as part of their implementation strategies. Major accomplishments that the hospital made during 2017 to promote an increase in access to Geriatric specialized care included being awarded the Joint Commission Disease Specific Certification in management of Dementia in 2017, which RRPH was one of only two Page 4

5 organizations nationally that received this certification. The hospital conducted Positive Physical Approach (PPA) to its clinical staff (RNs and PNAs) and RRPH s Gero Unit staff, as well as incorporating the PPA training into initial and annual mandatory training. The hospital also had a staff member achieve PAC Certified Independent Coach status in Finally, RRPH finalized the Aging Brain pamphlet detailing the timeline of Dementia. During the evaluation process for 2017, it became clear that Goal 1, Objective 1 Outreach to the community through Speaker s Bureau with Valley Hospital, Hackensack University Medical Center, Englewood Medical Center, YMCA, and partnerships with local schools to decrease stigma, and Goal 1, Objective 3 Participate in Stigma Free Wyckoff Day by collaborating with the Wyckoff School District to provide speakers on Stigma Free initiative, mental health and substance abuse are duplicative to Goal 1, Objective 2 Participate in Bergen County community events with a focus on health and wellness through outreach to the community. Therefore, Goal 1, Objective 1 and Goal 1, Objective 2 will be removed for 2018 and Other than these two objectives, all other goals and objectives will continue for 2018 and Methodology During February and August 2017 and February 2018, Ramapo Ridge Psychiatric Hospital (RRPH) conducted an evaluation of the Community Health Needs Assessment implementation strategies that have been underway over the last year. The evaluation process included: Submission and review of the outcomes and impact data that was tracked and reported during the last fiscal year, with an introduction meeting held on February 16, 2017 and a six-month update meeting held on August 10, Discussion of the accomplishments and next steps identified during an evaluation meeting held with RRPH hospital representatives on February 15, A total of two (2) hospital representatives participated in the Year 1 evaluation process through a wrap-up session. This evaluation meeting was facilitated by Kathy Roach, Community Health Improvement Project Manager from Strategy Solutions, Inc. The year-end evaluation meeting consisted of reviewing what was accomplished for 2017, reporting what were the strengths and areas for improvement for each of the goals and objectives and discussing whether RRPH will continue with the objectives and actions steps for Year 2. The participants included: Name Rebecca Dauerman, APN Cathy Pilone, RN, MSN, NEA-BC Title Vice President/Administrator of Mental Health Services Director of Service Excellence/Patient-Resident Experience Page 5

6 Progress Reports and Evaluation Discussion Goal 1: In Collaboration with Stigma Free Wycoff, Increase Awareness of Mental Health and Substance Abuse through Educational Outreach Offerings Objective 1: Outreach to the community through Speaker s Bureau with Valley Hospital, Hackensack University Medical Center, Englewood Medical Center, YMCA, and partnerships with local schools to decrease stigma with a minimum of 1 outreach per quarter with a focus on stigma free targeted awareness and completion of program evaluation(s) for events attended Through the evaluation process, it was determine that this objective was duplicative to Objective 2 below. Therefore, this objective will be removed for Years 2018 and Objective 2: Continue to participate in Bergen County community events with a focus on mental health and wellness through outreach to the community January Partnered with The Valley Hospital to participate in a Webinar related to Anxiety. A total of 36 attendees were registered for this event. Attended Career Fair at Ridgewood High School for the RAHP Program [Ridgewood Academy of Health Professions]--provided materials re CHCC and the mental health profession to high school students. February Presented at Midland Park Church on child/adolescent mental health topic. March CHCC Mental Health Division clinical staff and Stigma-Free ambassador participated in Wyckoff YMCA National Healthy Kids Day event. April Attended the BRMC Stigma Free Flag Raising event at BRMC. This was followed by a networking event and round table discussion related to future Stigma Free events. May Represented CHCC at the Bergen County Care Fair on Sunday 4/23/16 June MH Services staff participated in community event (Wyckoff Day) to support health and wellness. July Met with Wyckoff clergy at ECCR today to provide an overview of the Stigma Free initiative Page 6

7 November Clinicians from CHCC Counseling Center will partner with The Valley Hospital to participate in an event to support mental health for veterans. Director of SW partnered with Pastoral Care for presentation on Domestic Violence to local parishes. The standardized program evaluation template is in development and will be instituted in Year 2. Kathy asked for comments regarding Objective 2: Cathy Pilone is Chair of the Stigma Free Initiative in Wyckoff. RRPH is organizing a questionnaire to better capture information. Kathy then asked the participants to comment on what worked well about the implementation strategies related to participating in Bergen County community events with a focus on health and wellness through outreach to the community. Comments included: Our brand in the community. Level of expertise of our speakers. Partnering with community organizations, i.e., YMCA - due to their name in the community draws more people; strategically partner for a broader reach. Strong organizational support especially through Stigma Free time and resources to make the outreach event a successful. Kathy then asked for any areas of improvement regarding this objective. Comments included: Capture and anlayze data intent to change behavior and institute a follow-up protocol Opioid Coalition among the 6 hospitals what do we want to target, what do we want to do collaboratively; with the New Jersey Innovative Institute looking at what can be done regarding the high utilizers and Southern NJ coalition; have government interest Kathy posed the question should this objective be continued for Year 2. The response was yes. Objective 3: Participate in Stigma Free Wycoff Day by collaborating with the Wycoff School District to provide speakers on Stigma Free initiative, mental health and substance abuse. When reviewing this objective during the 6-month evaluation, it was determined that this objective should be part of Objective 2 above. Therefore, this objective will be removed for Years 2018 and Objective 4: Focusing on non-mental health professionals, provide a Stigma Free Mental Health First Aid (MHFA) course for both adults and youth RRPH conducted an 8-hour course targeted to non-mental health professionals in December 2016 with 25 participants. Adult MHFA was held in December 2016 with a total of 25 attendees Planned for a MHFA for Youth in late 2017 but due to logistics had to move to March Page 7

8 Kathy then asked for comments regarding Objective 4: No comments as didn t happen in Kathy then asked the participants to comment on what worked well about the implementation strategies related to the Stigma-Free Mental Health First Aid courses for adults and youth. Comments included: No comment didn t happen yet Kathy then asked for any areas of improvement regarding this objective. If the schools ask again for this training, we will do it. The trainers mentioned that they weren t sure if they could still offer this training for free, and need 15 to make the training happen. Kathy posed the question should this objective be continued for Year 2. The response was yes. Objective 5: Reach out to the community through social media, including a monthly mental health blog In 2017, Mental Health related Blogs are posted on a monthly basis on the CHCC Internet page. A total of 91 page views for an average time spent on page of 42 seconds were recorded for mental health blogs posted on the CHCC Intranet. Kathy then asked for comments regarding Objective 5: Clearly would like to have more traffic Staff has enjoyed writing the blogs and are getting a bigger following Kathy then asked the participants to comment on what worked well about the implementation strategies related to reaching out to the community through social media, including a monthly mental health blog. Comments included: Getting participation from the experts to write this blog and marketing support to post it. Kathy then asked for any areas of improvement regarding this objective. Work with Marketing to see how to market the blog better, i.e., more outreach Link to blog from Stigma Free Wycoff More traffic NAMI or MHA, but not strongly organized. Kathy posed the question should this objective be continued for Year 2. The response was yes. Objective 6: Collaborate with other providers in cross continuum initiatives During 2017, a Mental Health Collaboration was formed with two other hospitals to bring a consistency to care to the region. While there were three meetings in late 2016 and early 2017, the Mental Health Collaboration was put on hold while the hospitals were sent a proposal to assume responsibility of Bergen Regional Medical Center that would be a mental health Page 8

9 facility. RRPH was informed in September of 2017 that their proposal wasn t accepted and the collaboration disbanded. RRPH is positioned to assist any hospital that requires their services No comments or discussion happened regarding this objective. This objective will continue for years 2018 and Goal 2: Increase Access to Geriatric Specialized Care Objective 1: Apply for and receive the Disease Specific Certification on Dementia from the Joint Commission June 2017, RRPH was awarded the Joint Commission Disease Specific Certification in the management of Dementia. RRPH is one of two organizations nationally to have received this certification. Clinical/Non-clinical PI Indicators submitted with application: o Prescribing of Antipsychotic Medications and monitoring EKG to assess for Qtc Interval prolongation o Use of an Evidenced-Based Assessment tool implementation of the Cohen-Mansfield Agitation Inventory (CMAI) o RN and NA staffing ratios o Education on Positive Physical Approach Updated Clinical/Non-Clinical PI indicators that will be initiated 3rd quarter of 2017: o Utilization of alternative interventions for the management of insomnia (decreased use of hypnotic medications) o Family/Caregiver Education sessions o Patient/Family Satisfaction with identified elements of the treatment program (Activities, Medication Education and Patient/Family programs. o Provision of a hand-off communication tool with recommendations of interventions that have successfully been implemented to reduce identified behaviors Kathy then asked for comments regarding Objective 1: This is an every two year certification. Kathy then asked the participants to comment on what worked well about the implementation strategies related to applying for and receiving the Disease Specific Certification on Dementia from the Joint Commission. Comments included: Interdisciplinary process; leadership buy-in. The quality of the patient care is the by-product of this work. P Fact member engaged Kathy then asked for any areas of improvement regarding this objective. P Fact member whose family member had been a patient and has given a lot of good insight Kathy posed the question should this objective be continued for Year 2. The response was yes. Page 9

10 Objective 2: Focus on the philosophy of Dementia care by developing staff competency in evidenced-based dementia care During 2017 a total of 480 CHCC Clinical staff (RNs and PNAs) have been trained in the Positive Physical Approach (PPA). 260 CHCC staff attended a live training with Teepa Snow. RRPH Gero Unit C wing staff have all been educated and demonstrated competency in the Positive Physical Approach (PPA) as an evidenced-based intervention model to be used in engagement with patients. PPA is incorporated into CPI initial and annual mandatory training for mental health competencies. Staff member achieved PAC Certified Independent Coach in Provided in vivo real time training side by side with staff for a total of 128 hours. Focused education to target interventions with high acuity (cognitive impairment and problematic behaviors) to improve quality indicators of patient treatment and outcomes focus on education and training for additional clinical and non-clinical staff in the Positive Physical Approach (PPA). Kathy then asked for comments regarding Objective 2: For mental health incorporated into our CPI (crisis prevention institute) training, on C wing where the program is and also an annual competency Moving through our coach has met with EVS staff, Dietary staff, rehab through organization and now meeting with outside departments for training. Kathy then asked the participants to comment on what worked well about the implementation strategies related to focusing the philosophy of dementia care by developing staff competency in evidence-based dementia care. Comments included: The staff felt it was a meaningful skill Offered it to off shift and weekends- took the training to them. Posted on Intranet Kathy then asked for any areas of improvement regarding this objective. For 2018, tie resident incidents, i.e., acting out, if the PPA is making a difference look at rates of incidents of patient act out for C wing and long-term care. Look at root cause analysis to see if PPA was instituted would the patient not be injured. Kathy posed the question should this objective be continued for Year 2. The response was yes. Page 10

11 Next Steps The next steps include: Updating the action plan for the next year. Submitting the evaluation report to Hackensack Meridian Health s corporate 990, since RRPH is a for-profit hospital. Keeping track of the numbers and creating mechanisms for outcomes measurements so that RRPH can be included in the next CHNA. Page 11

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13 Appendix A Christian Health Care Center Ramapo Ridge Psychiatric Hospital Year Implementation Strategy Evaluation Page 13

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15 Mental Health and Substance Abuse Goal 1: In collaboration with Stigma Free Wyckoff, increase awareness of mental health and substance abuse through educational outreach Objective Objective 1 Outreach to the community through Speaker s Bureau with Valley Hospital, Hackensack University Medical Center, Englewood Hospital and Medical Center, YMCA and partnerships with local schools to decrease stigma Action Steps Minimum of 1 outreach per quarter with a focus on stigma free targeted awareness Completion of program evaluation(s) for events attended Outcomes Measurement # of events # of participants # of evaluations given # of evaluations returned January 1-December 31, 2017 Outcomes Measurements Comments This objective is duplicative to Objective 2 below and will be removed for years 2018 and 2019; all information is combined into Objective 2 Objective 2 Participate in Bergen County community events with a focus on health and wellness through outreach to the community Minimum of 2 events per year to provide information on mental health and wellness # of events # of participants January Partnered with The Valley Hospital to participate in a webinar related to Anxiety. A total of 36 attendees were registered for this event Attended career fair at Ridgewood High School for the RAHP Program (Ridgewood Academy of Health Professions) provided materials re: CHCC and the mental health profession to high school students February Presented at Midland Park Church on child/adolescent mental health topic Page 15

16 Mental Health and Substance Abuse Goal 1: In collaboration with Stigma Free Wyckoff, increase awareness of mental health and substance abuse through educational outreach Objective Action Steps Outcomes Measurement January 1-December 31, 2017 Outcomes Measurements March CHCC Mental Health Division clinical staff and Stigma-Free ambassador participated in Wyckoff YMCA National Healthy Kids Day event April Attended the BRMC Stigma Free Flag Raising event at BRMC. This was followed by a networking event and round table discussion related to future Stigma Free events May Represented CHCC at the Bergen County Fair June MH Services staff participated in community event (Wyckoff Day) to support health and wellness July Met with Wyckoff clergy at ECCR to provide an overview of the Stigma Free initiative Comments Page 16

17 Mental Health and Substance Abuse Goal 1: In collaboration with Stigma Free Wyckoff, increase awareness of mental health and substance abuse through educational outreach Objective Objective 3 Participate in Stigma Free Wyckoff Day by collaborating with the Wyckoff School District to provide speakers on Stigma Free Initiative, Mental Health and Substance Abuse Objective 4 Focusing on nonmental health professionals, provide a Stigma Free Mental Health First Aid course for both adults and youth Objective 5 Reach out to the community through social media, including a monthly mental health blog Action Steps Offer 8-hour course targeted to nonmental health professionals with a minimum of 2 courses provided annually with attendance of 15 or greater Have a different author each month will write information and respond to comments Outcomes Measurement # of speakers Topics presented # of participants # of courses provided # of participants # completing the program # of views # of comments received # of comments responded to January 1-December 31, 2017 Outcomes Measurements November Clinicians from CHCC Counseling Center will partner with The Valley Hospital to participate in an event to support mental health for veterans Director of SW partnered with Pastoral Care for presentation on Domestic Violence to local parishes Adult Mental Health First Aid was held in December 2016 with a total of 25 attendees 2017 course was postponed until 2018 Mental health related blogs are posted on a monthly basis on the CHCC internet page. A total of 91 page views for an average time spent on page of 42 seconds was recorded for mental health blogs posted Comments This objective is duplicative to Objective 2 above and will be removed for years 2018 and 2019; all information is combined into Objective 2 Page 17

18 Mental Health and Substance Abuse Goal 1: In collaboration with Stigma Free Wyckoff, increase awareness of mental health and substance abuse through educational outreach January 1-December Outcomes 31, 2017 Outcomes Objective Objective 6 Collaborate with other providers in cross continuum initiatives Action Steps Measurement # of initiatives collaborated on Measurements During 2017, a Mental Health Collaboration was formed with two other hospitals to bring a consistency to care to the region. While there were three meetings in late 2016 and early 2017, the Mental Health Collaboration was put on hold while the hospitals were sent a proposal to assume responsibility of Bergen Regional Medical Center that would be a mental health facility. RRPH was informed in September of 2017 that their proposal wasn t accepted and the collaboration disbanded. RRPH is positioned to assist any hospital that requires their services Comments Page 18

19 Mental Health and Substance Abuse Goal 2: Increase Access to Geriatric Specialized Care January 1-December Objective Action Steps Outcomes Measurement 31, 2017 Outcomes Measurements Objective 1 Become certified and Receive Disease June 2017, RRPH Apply for Disease follow outcomes (2 Specific was awarded the Specific clinical and 2 non-clinical Certification on Joint Committee Certification on measures submitted with Dementia Disease Specific Dementia from application to be Certification in the the Joint monitored management of Commission Dementia Clinical/Non-Clinical PI indicators submitted with application: o Prescribing of Antipsychotic Medications and monitoring EKG to access for Qtc Interval prolongation o Use of an evidenced-based assessment tool implementation of the Cohen- Mansfield Agitation Inventory (CMAI) o RN and NA staffing ratios o Education on positive physical approach Updated clinical/nonclinical PI indicators that was initiated in 3 rd quarter 2017: o Utilization of alternative interventions for the management of insomnia (decreased use of hypnotic medications) o Family/caregiver education sessions Comments CHCC is one of 2 organizations nationally to have received this certification Page 19

20 Mental Health and Substance Abuse Goal 2: Increase Access to Geriatric Specialized Care January 1-December Objective Action Steps Outcomes Measurement 31, 2017 Outcomes Measurements o Patient/family satisfaction with identified elements of the treatment program (activities, medication education and patient/family programs o Provision of a hand-off communication tool with recommendations of interventions that have successfully been implemented to reduce identified behaviors Objective 2 Conduct staff education # of trainings During 2017, a total Focus on and competency conducted of 480 CHCC philosophy of evaluation for Positive # of participants Clinical staff (RNs Dementia care by Physical Approach (PPA) and PNAs) were developing staff trained in the PPA. competency in 260 CHCC staff evidenced-based attended a live dementia care training with Teepa Snow PPA has been incorporated into CPI initial and annual mandatory training for mental health competencies Staff member achieved PAC Certified Independent Coach Comments RRPH Gero Unit C wing staff have all been educated and demonstrated competency in the PPA as an evidenced-based intervention model to be used in engagement with patients focus on education and training for additional clinical and nonclinical staff in the PPA. Page 20

21 Mental Health and Substance Abuse Goal 2: Increase Access to Geriatric Specialized Care January 1-December Objective Action Steps Outcomes Measurement 31, 2017 Outcomes Measurements Objective 3 Conduct community Presentation 163 community Continue to presentation by nationally conducted members attended provided recognized expert in Attendance of 50+ Teepa Snow s education evidenced-based care training on the outreach to Fundamentals of community for Dementia and education related addressed the needs to Dementia of individuals with Dementia Actively engaged a PFAC comprised of 9 community members and 3 CHCC staff PFAC meets monthly to address patient/family experiences of care delivery model PFAC finalized Aging Brain pamphlet detailing the timeline of Dementia Comments Action item that will be removed from the implementation strategy action plan for years 2018 and 2019: Objective Action Steps Reason for Removal Goal 1 Objective 1 Outreach to the community through Speaker s Bureau with Valley Hospital, Hackensack University Medical Center, Englewood Hospital and Medical Center, YMCA and partnerships with local schools to decrease stigma Minimum of 1 outreach per quarter with a focus on stigma free targeted awareness Completion of program evaluation(s) for events attended Goal 1 Objective 3 Participate in Stigma Free Wyckoff Day by collaborating with the Wyckoff School District to provide speakers on Stigma Free Initiative, Mental Health and Substance Abuse Duplicative action step to Goal 1, Objective 2: Participate in Bergen County community events with a focus on health and wellness through outreach to the community Duplicative action step to Goal 1, Objective 2: Participate in Bergen County community events with a focus on health and wellness through outreach to the community Page 21

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23 Appendix B Christian Health Care Center Ramapo Ridge Psychiatric Hospital Year Implementation Strategy Evaluation Page 23

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25 Mental Health and Substance Abuse Goal 1: In collaboration with Stigma Free Wyckoff, increase awareness of mental health and substance abuse through educational outreach Outcomes Objective Objective 1 Participate in Bergen County community events with a focus on health and wellness through outreach to the community Objective 2 Focusing on non-mental health professionals, provide a Stigma Free Mental Health First Aid course for both adults and youth Objective 3 Reach out to the community through social media, including a monthly mental health blog Objective 4 Collaborate with other providers in cross continuum initiatives Action Steps Minimum of 2 events per year to provide information on mental health and wellness Offer 8-hour course targeted to nonmental health professionals with a minimum of 2 courses provided annually with attendance of 15 or greater Have a different author each month will write information and respond to comments Measurement # of events # of participants # of courses provided # of participants # completing the program # of views # of comments received # of comments responded to # of initiatives collaborated on Page 25

26 Mental Health and Substance Abuse Goal 2: Increase Access to Geriatric Specialized Care Objective Objective 1 Main CHCC s Disease Specific Certification on Dementia from the Joint Commission Objective 2 Focus on philosophy of Dementia care by developing staff competency in evidenced-based dementia care Objective 3 Continue to provided education outreach to community for education related to Dementia Action Steps Become certified and follow outcomes (2 clinical and 2 non-clinical measures submitted with application to be monitored Conduct staff education and competency evaluation for Positive Physical Approach (PPA) Conduct community presentation by nationally recognized expert in evidenced-based care Outcomes Measurement Maintain Disease Specific Certification on Dementia # of trainings conducted # of participants Presentation conducted Attendance of 50+ Action item that will be removed from the implementation strategy action plan for years 2018 and 2019: Objective Action Steps Reason for Removal Goal 1 Objective 1 Outreach to the community through Speaker s Bureau with Valley Hospital, Hackensack University Medical Center, Englewood Hospital and Medical Center, YMCA and partnerships with local schools to decrease stigma Minimum of 1 outreach per quarter with a focus on stigma free targeted awareness Completion of program evaluation(s) for events attended Goal 1 Objective 3 Participate in Stigma Free Wyckoff Day by collaborating with the Wyckoff School District to provide speakers on Stigma Free Initiative, Mental Health and Substance Abuse Duplicative action step to Goal 1, Objective 2: Participate in Bergen County community events with a focus on health and wellness through outreach to the community Duplicative action step to Goal 1, Objective 2: Participate in Bergen County community events with a focus on health and wellness through outreach to the community Page 26